Provider Demographics
NPI:1518047257
Name:SIDER, ROGER C (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:C
Last Name:SIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 S BUTLER ROAD
Mailing Address - Street 2:
Mailing Address - City:MT GRETNA
Mailing Address - State:PA
Mailing Address - Zip Code:17064-0550
Mailing Address - Country:US
Mailing Address - Phone:800-932-0359
Mailing Address - Fax:
Practice Address - Street 1:283 S BUTLER ROAD
Practice Address - Street 2:
Practice Address - City:MT GRETNA
Practice Address - State:PA
Practice Address - Zip Code:17064-0550
Practice Address - Country:US
Practice Address - Phone:800-932-0359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-069099-L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017785800001Medicaid
PA0017785800001Medicaid
B48959Medicare UPIN